Read Affidavit of Inability to Pay Court costs text version

Case No: ____________________

(Print court information, exactly as it appears on your Petition)

In the (check one): District County

Justice Court of:

_______________________ County, Texas

Affidavit of Inability to Pay Costs

State of TexasCounty of ______________________________________

(Print the name of county where this statement is notarized)

The person who signed this affidavit appeared, in person, before me, the undersigned notary, and stated under oath: "My name is __________________________________. I am above the age of eighteen (18) years, and I am fully competent to make this affidavit. The facts stated in this affidavit are within my personal knowledge and are true and correct. My income, resources, and expenses are described below.

Monthly Income Net Employment Public Benefits Other Income * Spouse's Income

Describe source of income:

Amount

$ $ $ $ Total Monthly Income $

* List your spouse's income ONLY IF your spouse contributes to your household income.

Number of Dependents (Include yourself and your dependents) Property Cars or Trucks

Year: Make: Year: Make: Bank: Bank:

Checking Account Amount $ Savings Account Amount $ Cash Amount $ Other Property

(Do not list the home where you live)

Monthly Expenses Rent/Mortgage $ Car Payment $ Transportation $ Insurance $

Total Monthly Expenses $

Food $ Medical/Dental $ Clothing/Laundry $

Child Care $ Utilities $ Other: $

Texas Affidavit of Inability to Pay Costs, March 2011 Partnership for Legal Access

Page 1 of 2

Debts and child support obligations* Who do you make payments to? Creditor Creditor Creditor Creditor Creditor Creditor

*Do not include house payments and automobile payment.

monthly payment: $ $ $ $ $ $

Total Monthly Debt Payment

$

"I am unable to pay court costs. I verify that the statements made in this affidavit are true and correct."

Do not sign until you are in front of a notary.

Signature

Date

Notary fills out below. State of Texas, County of

(Print the name of county where this statement is notarized)

Sworn to and subscribed before me, the undersigned notary, on this date: By

(Print name of person who is signing this affidavit.):

.

(Notary's seal here) Notary's signature

Texas Affidavit of Inability to Pay Costs, March 2011 Partnership for Legal Access

Page 2 of 2

Information

Affidavit of Inability to Pay Court costs

2 pages

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